Splenectomy for splenomegaly and secondary hypersplenism

Splenomegaly and secondary hypersplenism may be associated with acute and chronic infections, autoimmune states, portal hypertension or splenic vein thrombosis, and a number of infiltrative and neoplastic conditions involving the spleen. Our experience and that of others with these various conditions demonstrates that the decision to perform splenectomy should be based on well-defined and often strictly limited indications. Except for idiopathic splenomegaly, the presence and severity of secondary hypersplenism or severely symptomatic splenomegaly should be well documented. In each case, the potential for palliation and known mean duration of expected response must be weighed against the increased morbidity and mortality of splenectomy (as compared to operation for “primary” hypersplenism) . La splénomégalie avec hypersplénisme secondaire relève de multiples causes: infection aigue ou chronique, états autoimmunologiques, hypertension portale, thrombose de la veine splénique, lésions tumorales spléniques. L'expérience de l'auteur qui rejoint celle de nombreux collègues lui permet d'affirmer que les indications de la splénectomie doivent être bien définies et sont strictement limitées. A l'exception de la splénomégalie idiopathique, l'existence et l'intensité de l'hypersplénisme, l'importance des symptomes provoqués par la splénomégalie doivent être aprréciées avec précision. Dans chaque cas le potentiel de la rémission de l'affection et la durée de la rémission doivent être pris en considération en fonction de l'éventuelle morbidité et de l'éventuelle mortalité de la splénectomie (par comparaison avec la splénectomie pour hypersplénisme primaire). Eplenomegalia e hiperesplenismo secundario pueden estar asociados con infecciones agudas y crónicas, estados autoinmunes (síndrome de Felty, lupus eritematoso sistémico), “esplenomegalia congestiva” por hipertensión portal o trombosis de la vena esplénica y con una variedad de entidades de tipo infiltrativo y neoplásico que afectan al bazo (sarcoidosis, enfermedad de Gaucher, varios desórdenes mieloproliferativos y linfomas). Nuestra experiencia, y aquella de otros autores, con tales condiciones demuestra que la decisión de realizar esplenectomía debe estar fundamentada en indicaciones bien definidas y estrictamente limitadas. Excepto en casos de esplenomegalia idiopática, la presencia y severidad del hiperesplenismo secundario o de esplenomegalia severamente sintomática debe ser bien documentada. En cada caso debe determinarse el potencial de paliación y la duración de la respuesta que se espera obtener frente a la incrementada morbilidad y mortalidad de la esplenectomía (en comparación con la operación que se realiza por hiperesplenismo “primario”).Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/41318/1/268_2005_Article_BF01655279.pd

The effect of combined modality therapy on local control and survival

The systemic component of combined modality therapeutic programs has influenced both the selection of the approach to local control and survival in a number of tumor types. The more effective systemic therapy is against metastatic cancer by itself, the greater the impact on local control and survival. This observation is consistent with the invariable inverse relationship between curability and tumor cell number. For some common cancers, local control is good, but survival remains poor because of the inability to deal effectively with micrometastases. Improved systemic treatment is likely to have an impact on survival may shift local control measures, in some cases, to radiation therapy or lesser surgery without radiation therapy. There remains a substantial number of tumor types where both local control and survival is poor. In these tumors, improvement in local control by itself is not likely to improve survival because of the presence of micrometastases, but such improvements must occur before we can have a true evaluation of the systemic treatment of micrometastases in these tumors. The recent understanding that the metastatic process is under genetic control and the cloning of metastases genes offers a substantial opportunity to control this process and influence both local control and survival